Abstract
Sexual dysfunction is present in almost every patient with chronic pelvic pain and often is a most significant problem that patients experience. This is in addition to a significant decrease of quality of life from pain that further stigmatizes those very unfortunate patients. Patients who are unable to have intercourse are often abandoned by their partners and often are not able to find new partners. Sexual dysfunction therefore has to be taken very seriously and it should be addressed with both partners. Couples should be told that cure is possible and alternatives to vaginal intercourse should be discussed. Often pelvic floor muscle spasm is responsible for pain with intercourse and treatment of that condition is discussed in Chapter 20.
Editor’s Introduction
Sexual dysfunction is present in almost every patient with chronic pelvic pain, and often is the most significant problem that patients experience. This, in addition to a significant decrease of quality of life from pain, further negatively affects patients. Those who are unable to be intimate, may be abandoned by their partner, and not able to form new relationships. Sexual dysfunction therefore has to be taken very seriously, and it should be addressed with both the patient and her partner. Couples should be told that cure is possible and alternatives to vaginal intercourse should be discussed. Pelvic floor muscle spasm is often responsible for pain with intercourse. Treatment of this condition is discussed in Chapter 20.
Introduction
Women experience optimal sexual health through psychosomatic connection to their own bodies, synchronicity with their intimate partner(s), and through rewarding experiences with life overall. Sexual intimacy is a primary vehicle for that connection. Initially, with self-exploration, a woman discovers unique pathways to pleasure that later become reliable and reproducible, with a partner. Then, as partnered sexual activity becomes routine, she learns how her body functions when synchronized with another. Finally, as she actualizes in life, maturing through life goals – as a partner, perhaps as a mother, and/or in a career role, she develops the confidence, inner happiness, and serenity that play into satisfaction with the sovereignty derived from expressing her sexuality on her own terms, by her own definition.
The holistic, or biopsychosocial approach to sexual function is well established in medical diagnosis and treatment – especially with regard to interventions for sexual concerns [1]. Tenets of this view include physical health, with appropriate neuroendocrine function; psychological wellness, with freedom from mood disrupters such as anxiety and depression; social/cultural acceptance within one’s group(s); and the importance of relationship satisfaction, interpersonal competence, financial adequacy, and freedom from life stressors [2].
Blocks and barriers to sexual wellness are common in society, and as a result, sexual dysfunction is also prevalent, estimated to affect up to 43% of women worldwide – peaking at midlife, ages 45–64 [3, 4]. Similarly, chronic pelvic pain is common, striking one in seven women [5], and up to 26% of women worldwide [6], also increasing with age [7]. Overall health is an important predictor of satisfaction with sex – and multiple chronic health conditions exert a toll on sexual function more strongly than age alone [8].
Sexual concerns that persist for at least 6 months and cause personal distress are classified as “dysfunctions.” However, in the true sense of holistic sexuality, wellness is more than absence of dysfunction – and must evoke elements of fulfillment in the physical, intellectual, emotional, and relational aspects of sexual being.
Classification of Sexual Dysfunctions
The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), the gold standard reference of psychiatric and behavioral disorders, refers to sexual dysfunction as a “heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” [9]. The term female sexual dysfunction encompasses gender-specific disorders outlined in the DSM-5, and an individual may have more than one sexual dysfunction simultaneously:
1. Female sexual interest/arousal disorder (FSIAD): – Formerly termed hypoactive sexual desire disorder and female sexual arousal disorder – two separate entities in the DSM-4
2. Female orgasmic disorder
3. Genito-pelvic pain/penetration disorder: Formerly dyspareunia and vaginismus in DSM-4
Sexual dysfunctions are subtyped according to “lifelong versus acquired” and “generalized versus situational.” The disorder must be experienced at least 75% of the time, cause significant distress, and be present for at least 6 months in order to qualify for the diagnosis.
A group of criteria called “associated features” provides five additional categories:
1. Partner factors (partner sexual problem; partner health status)
2. Relationship factors (poor communication, discrepancies in desire for sexual activity)
3. Individual vulnerability factors (poor body image; history of sexual or emotional abuse), psychiatric comorbidity (depression; anxiety), or stressors (job loss; bereavement)
4. Cultural or religious factors (inhibitions related to prohibitions against sexual activity or pleasure; attitudes toward sexuality)
5. Medical factors relevant to prognosis, course, or treatment [10]
Healthcare providers must be familiar with these classifications in order to recognize and intervene in the evolution of overlapping dysfunction in mood, behavior, and sexuality as one responds to life experience in the context of chronic pain.
The Female Sexual Response Cycle
The female response cycle has undergone revisions through the decades, as more information is gleaned about the ways women experience the pathway from desire and arousal to orgasm and beyond. A contemporary model, developed by Rosemary Basson, is a circular-type pathway, which takes into accounts the mind–body relationship of sexual function (Figure 19.1) [11]. It is crucial to understand this model, in order to make sense of the effects of chronic pain on sexuality. Mindset affects physiological function, and chronic pain alters the psyche.
Figure 19.1 Circular sexual response cycle. Circular sexual response cycle shows overlapping phases of variable order. Reasons or motivations for sex are numerous, and sexual desire or drive may or may not be present at the outset but reached after the brain has processed sexual signals as sexual arousal, which conflates with sexual desire. The latter creates an urge for increased arousal, allowing acceptance of increasingly intense sexual stimulation.
This nonlinear model of sexual response incorporates the importance of intimacy/attachment, or the relationship aspect of motivation. It also explains that desire can be responsive or spontaneous, and that arousal can occur before, or after desire. Orgasm contributes to the reward component and reinforces motivation for more desire and arousal. This model normalizes the variability within desire and arousal, making it clear that the interplay between motivation, interest, arousal, desire, and orgasm is far from simple or straightforward. When chronic pelvic pain enters the situation, it affects many points along the sexual response model – shutting down arousal, preventing desire, and preempting intimacy, with emotions like resentment, disappointment, and shame. All points within the circular algorithm must be restored as much as possible in order to provide “flow” once again to sexual satisfaction.
Effects of Chronic Pelvic Pain on Sexual Well-Being
Chronic gynecological pain has more far-reaching and all-encompassing effects on a woman than chronic pain arising from most other body regions because of the secondary effects it creates on the psychosocial factors related to sexual intimacy and intimate relationships. Optimal sexuality is derived from interrelated aspects of physical condition, intellectual beliefs, emotional responses, and relational connections in equal and profound ways. Until blocks and barriers in all these areas can be identified and resolved, true well-being and sexual health cannot be fully achieved.
Considering the sexual response cycle once again (Figure 19.1), one sees that impediments at any entry area, such as willingness, anticipatory desire, or subjective arousal can alter the flow of response, even stopping it. Physical pain is an obvious impediment; however, less apparent, more subjective, negative facets such as poor body image or low self-esteem, along with depression or anxiety, are just as destructive for the sexual response cycle.
Effects of Chronic Pelvic Pain on Mood
Chronic pelvic pain is correlated with significant levels of psychological distress and functional impairment; with more than half of women experiencing moderate-to-severe anxiety, and more than one-quarter with moderate-to-severe depression [12]. There is significant overlap between sexual dysfunction and depression, as seen in many prior studies. It follows, therefore, that chronic pelvic pain closely impacts the two related spheres of depressed or anxious mood and sexual dysfunction by being a stimulus for either or both. The medications used for the treatment of depression typically have a negative impact on the sexual function of women, though some have found the dopaminergic action of bupropion beneficial, and others advocate the possibility of using more traditional antidepressant medications – either at a lower dose, or providing occasional drug holidays to alleviate side effects.
Effects of Chronic Pain on Body Image
Chronic pelvic pain has a negative effect on female body image, and when body image is compromised, it impacts sexual function and satisfaction. Women may either develop a hypervigilant, obsessive focus on the painful part of the body, or complete dissociation and reduced awareness of the area. Women with chronic gynecological pain may have increased body exposure anxiety during sexual activities, especially if the pain is primary rather than developed secondarily [13]. A woman with primary chronic pelvic pain has not had a chance to develop a positive appreciation for her body, and its ability to function sexually in a pleasurable way. When the pelvic structures have always been a source of pain and distress, it is extremely difficult to experience normal sexual development, and unimpaired experiences of desire, arousal, or orgasm. Conversely, with chronic pelvic pain developed secondarily, a woman has had a span of healthy sexual function to provide a frame of reference – and a concrete cognitive goal to work back toward, as she takes steps to resolve the pain and return to prior levels of optimal function. It is important to establish whether chronic pelvic pain is primary or secondary, in order to evaluate and treat it effectively, as the two have different therapeutic trajectories. It is also helpful to address a woman’s feelings about her body, and beliefs about her genital function, as these views are integral in planning holistic treatment [14].
Effects of Chronic Pain on Relationship/Intimacy
It is indisputable that chronic pelvic pain negatively affects relationship dynamics of the couple involved. It also follows that the quality of the relationship then likely influences the degree and intensity of the pain. This dynamic can have various presentations, from the virginal couple that marries, and then discovers that the female has pelvic floor tension and spastic pain, to the long-married couple that deals with pelvic pain from adhesive disease following multiple surgeries. It is crucial to enquire about how each partner has adjusted to pain within the relationship, and how he or she has navigated the ensuing difficulties with intimacy. It has been reported that male partner behavior has a modulatory effect on female sexual satisfaction. Increased facilitative, and decreased negative responses relate to higher sexual and relationship satisfaction, whereas more solicitous behavior on the part of the male creates less sexual satisfaction for both [15]. It is important to help the couple acknowledge these behavior patterns and provide a framework by which to rework them in order to circumvent continued negativity and reinforce positive relational satisfaction. The suggestion that partners’ cognitive responses may influence the experience of chronic pelvic pain for women points toward the importance of considering and including the partner when treating this sexual health problem.
Tools to Evaluate Biopsychosocial Aspects of Female Pain
It is important to have efficient tools at hand in the clinical setting, to quickly identify all patients at risk for sexual dysfunction, in order to either deal with the problem(s) or provide appropriate referral for them.
Female Sexual Function Index
One comprehensive tool is the Female Sexual Function Index (FSFI) [16]. It is a 19-item measure of female sexual function yielding a total score, as well as individual scores relating to the six domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI questions are coded from 0.0 to 5.0, with the maximum score for each domain being 6.0. Summing item responses and multiplying by a correction factor derives the final score. The total composite sexual function score ranges from 2.0 (reflecting no sexual activity/no desire) to a high score of 36. An FSFI score of 19 or lower correlates to sexual dysfunction, with the specifics being identified by analyzing each of the domains. This comprehensive tool is useful in the research setting, but one drawback is that it requires considerable time for a woman to respond to the entire questionnaire. The provider must then take time to score the questionnaire, making it unwieldy in the busy clinical setting.
Female Sexual Dysfunction Index
One adaptation for the clinical setting is the Female Sexual Dysfunction Index (FSDI) (Figure 19.2), which is based on a shortened version of the FSFI, but features an additional item related to personal interest in having a satisfying sex life. The item rating sexual arousal was removed. The total score can range from 2 to 30, with a pathological sum considered ≥16 [17]. This tool is especially suited to nonspecialist settings, to quickly detect potential female sexual dysfunction (FSD), which could otherwise remain underrecognized.
Figure 19.2 Female Sexual Dysfunction Index (FSDI). The score for each of the six items is added and total derived. A pathological sum is considered ≥16.
Effects of Chronic Pain on Desire
The psychological implications of chronic pelvic pain exert a consistent effect on sexual function for women – especially with regard to desire for sexual activity. When chronic pain conditions comorbid circumstances in the pelvic floor and vagina to trigger more intense pain through pelvic floor tension, or vaginal spasm, it becomes very unlikely for a woman to experience either spontaneous or responsive-type sexual desire. Further, the high levels of anxiety and depression seen in women with chronic pelvic pain reduce the potential for sexual desire and arousal, both from central “shut-down” mechanisms resulting from alterations in brain neurochemistry, as well as local dryness, pain, and lack of lubrication from the disease process directly, or as consequences of treatment interventions. It is important to recognize the stepwise nature that must be undertaken in treating sexual dysfunction, as it is unrealistic to expect improvement in desire/arousal before resolving or improving the root cause(s) of chronic pelvic pain as much as possible. Sexual desire becomes more elusive if pain as a barrier is not reduced. Prescriptions or interventions aimed at improving desire are futile in the setting of chronic pain.
Sexual Anatomy: Implications for Genital Structures
Female genital form and function continues to be clarified and classified even in contemporary times. Structures such as the Skene’s (paraurethral) glands, the clitoris, and the distal vagina are the focus of novel research further defining anatomical structure and physiological function in recent years. The concept of vaginal orgasm and the supporting role of anatomical structures in the anterior vaginal wall have garnered much interest of late, as consensus has shifted toward the clitoris, through its deeply rooted extensions underlying the labia, and diving deeply along the anterior vaginal wall, participating as more of a collaborative unit with the aroused anterior vaginal wall, rather than as a distinct entity. The “so-called” G spot is actually formed by an interactive, clitoral–urethral–vaginal complex, which is variable between women, due to diversity in relational measurements and routes of innervation [19]. These structures share some common vasculature and innervation and move in unison during sexual activity, especially when brought into even closer proximity during arousal through engorgement of genital tissues.
